Ah, the great mysteries of life. Which came first, the chicken or the egg? Is there intelligent life on other planets? Where do all the missing socks go? And of course, the enduring mystery: what is the interrupted stay policy?
Interrupted stays may not happen often, and every skilled nursing facility (SNF) stay is different—these circumstances can create confusion surrounding the interrupted stay policy, states Carol Maher, RN-BC, RAC-MTA, RAC-MT, RAC-CTA, RAC-CT, CPC, director of education for Hansen, Hunter & Co., PC, in Vancouver, Washington. “Not a day goes by that I don’t get questions on the interrupted stay policy. What is an interrupted stay? How is it calculated? How is it billed? What assessments are needed? How does an interrupted stay affect MDS coding on the Discharge assessment and subsequent assessments? Does it affect the physician certification and recertification schedule? How does the interrupted stay impact therapy services?” Since the introduction of the Patient-Driven Payment Model (PDPM), there have been more than one hundred questions on this subject in the AAPACN community alone. Confusion regarding the interrupted stay policy and its effects persists.
Why does the interrupted stay continue to be such a conundrum? In part, this policy is still a relatively new concept in the SNF world. Though modeled after an earlier policy, CMS implemented the interrupted stay policy with PDPM due to the addition of the variable per diem (VPD) adjustment schedule. Because the VPD schedule triples the non-therapy ancillary (NTA) portion of the payment for the first three days of the SNF stay, CMS sought to prevent facilities from discharging and readmitting residents just to reset the VPD adjustment schedule and take advantage of the higher NTA payment. As a result of the interrupted stay policy, the OBRA and PPS schedules are no longer aligned when a resident discharges and then returns during the interruption window. To add further complexity, the occurrence code used on the Medicare claim to report an interrupted stay is the same occurrence code used for a leave of absence, even though they are two distinctly different situations for the MDS department. So how can nurse assessment coordinators (NACs) and billing departments keep everything straight? AAPACN has some tools available to help clear up the mystery.
First, NACs need to understand what the interrupted stay policy entails. The Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual defines the interrupted stay as “a Medicare Part A SNF stay in which a resident is discharged from SNF care (i.e., the resident is discharged from a Medicare Part A-covered stay) and subsequently resumes SNF care in the same SNF for a Medicare Part A-covered stay during the interruption window.” The interruption window is defined as “a 3-day period, starting with the calendar day of Part A discharge and including the two immediately following calendar days.” The interrupted stay policy may affect the PPS assessment schedule, the variable per diem adjustment schedule, physician certification and recertification schedule, MDS coding, and billing for a Medicare Part A resident. “The physician certification/recertification is the first thing that is looked at during a medical review, and if it is not correct, the reviewer will close the case without looking at the record,” explains Maher. She continues, “If the staff member responsible for tracking the certification process does not understand the interrupted stay policy, this can impact the certification schedule and result in an invalid certification.”
Myth: The physician certification and recertification process must be restarted after every discharge and reentry into the SNF.
Fact: The certification/recertification schedule is based on calendar days, not Medicare days used. The schedule continues through an interrupted stay and does not skip the days during the interrupted stay. There is no extension to the physician certification scheduling requirements during the interrupted stay. The physician certification and recertification schedules only restart if there is a new stay. When a new 5-Day PPS assessment is required, the physician certification/recertification process restarts as well.
This information and more can be found in AAPACN’s new Interrupted Stay Policy Frequently Asked Questions (FAQ) and Resources tool. This FAQ, available for purchase on the AAPACN website, explains 24 of the most inquired-about scenarios to help the NAC and the biller understand the nuances of the interrupted stay policy. In addition to answers to these hot topic questions, there are also references to CMS regulations and further AAPACN resources that can assist the team. Examples demystify the process.
NACs may not have the luxury of reviewing a multi-page document to find answers when determining if a stay is interrupted or not. AAPACN’s Interrupted Stay Flow Chart is the perfect one-page guide to determining if a stay meets the criteria of an interrupted stay. This colorful flow chart will help the users to easily determine the type of stay.
Myth: The start date of the interrupted stay count is the date the resident is admitted to the hospital.
Fact: The resident’s status at the hospital (admitted, outpatient, observation stay) has no bearing on the interruption window calculation. The interruption window counts from the first non-covered Medicare day regardless of type of discharge. When an interrupted stay begins due to a physical discharge, the interruption window count starts with the date the resident physically left the building, not the date of the admission to the hospital.
“Software data entry could add to the confusion of the interrupted stay policy,” says Maher. How staff enter an admission, reentry, leave of absence, or discharge into the software affects how the software creates the claim and, in many cases with integrated clinical and financial software systems, the MDS schedule. Often, Maher continues, NACs have received instruction on the interrupted stay policy, but the staff entering census data may not have the same understanding. The interrupted stay policy determines when multiple SNF stays will be billed as one continuous Medicare stay (interrupted stay) or separate stays (new stay) during a benefit period. The term interrupted stay is synonymous with a continued stay in the realm of Medicare billing. If there is an interrupted stay, this is one continuous Medicare claim that had an interruption of less than three non-covered days during the claim period. An interrupted stay is reported on the Medicare claim with an occurrence span code of 74 with the FROM date equaling the first non-covered day and the THROUGH date equaling the last non-covered day. This occurrence span code should be reported for each interruption of more than one day. AAPACN’s Interrupted Stay Policy-Quick Guide provides an easy-to-understand, one-page graphic reference for NACs and billers to determine the requirements for whether the stays will be billed as one continuous interrupted stay or as two separate stays.
Myth: An interrupted stay requires separate claims.
Fact: The only time separate claims are required in a month would be if the resident was discharged for three or more consecutive days and returned to a skilled level of care at the same SNF.
In addition to understanding the nuances of the interrupted stay, the NAC also needs a process to track interrupted stays and to validate that the MDS and final claim are billed accurately. Many of the questions Maher receives on the interrupted stay are related to an interrupted stay that occurs in the first eight days of the stay. “They always ask ’Do I do an MDS before they left, or after they left?’” She explains that if the assessment reference date was already set prior to the resident’s discharge, the ARD can be moved to the date of discharge. However, if it was not set prior, “the only thing you can do is hope the resident returns during the interruption window; otherwise, you will have a missed assessment.” It’s important to ensure that the team tracks each discharge from Medicare at the time of discharge. If the interrupted stay was not calculated correctly, there could be a 5-Day PPS assessment completed that was not required or, worse, a missed 5-Day for a new stay that was thought to be interrupted. If a new stay is not calculated properly, and the error is not discovered until after the eighth day of the new stay, this could become a late or missed assessment. “Back in the days before automation, we would use large whiteboards in a centralized location to track if a resident returned from a hospitalization or not,” Maher explains, “and there would be discussion in the daily PPS meeting. Facilities should still be having these daily meetings to review the interrupted stays and ARD selections.” SNF staff can use AAPACN’s interactive Interrupted Stay Tracker spreadsheet to track each discharge from Medicare, whether it is a discharge from the facility or an end of skilled coverage while remaining a resident of the facility (Part A discharge). After the user enters the first non-covered day, the tracking tool calculates the end date of the interruption window. The tracking tool also allows the NAC to note whether or not Medicare skilled coverage was met on return to the SNF, if the completion of the PPS Part A Discharge assessment is needed, and whether there is a secondary payer during the interrupted stay. During the triple-check process, the tracking tool can help to confirm that the interrupted stay was properly communicated to the billing office and the days were appropriately noted on the claim as non-covered days.
Myth: The PPS assessment schedule restarts when a resident discharges, return not anticipated, to home, and returns to the SNF for a skilled need within the interruption window.
Fact: The interrupted stay must be calculated from any type of discharge from the facility. If the resident returns to the same SNF, covered under Medicare Part A, no later than 11:59 p.m. within the third consecutive calendar day from the discharge, this is an interrupted stay, even if the resident was discharged home. While an interrupted stay is a continuation of the previous stay for Medicare, since the resident was discharged with a return not anticipated, this scenario would require a new Admission assessment for the OBRA schedule.
NACs will likely continue to have questions regarding the interrupted stay policy, especially with new or unique situations that arise in the facility. However, having effective tools and resources at their fingertips will help the NAC navigate these situations with greater confidence.
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